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Monday, August 7, 2017

Hallux Limitus/Rigidus: Email Advice

Hi Doctor Blake,

I'm  desperate to find some pain relief for my big toes and your website offered such excellent advice to others I'd thought I'd seek your advice. I work in the movement field as a Pilates instructor and it's been devastating to be hobbled like this. I'm assuming I have hallux limitus since I have lost a lot of range of motion in my big toes in the last 2 years although if I think back, my feet started showing signs of what I though were bunions at least 5 years ago or more.When that happened I started wearing toe spacers religiously and trying to strengthen my big toe abductors. That didn't stop the progression of what was to come.

2 years ago both big toes suddenly seized up and were unable to extend at all! I have no idea what set this off-perhaps the fact I was doing a lot of walking in minimalist shoes at the time (which I tried because all my old shoes such as Keens were hurting my feet and only the flexible minimalist soles were comfortable! ) Maybe because I was doing a lot of exercises  kneeling on my shins with my toes tucked under (I can't even imagine doing that now!)  

I had to wear closed Birkenstock clogs to even walk to the subway when the toes first seized up. I used to walk easily 2 hours  a day to get to work and back. And suddenly I could barely walk-when this first started I even had to wear Birkenstock sandals indoors but since then luckily I can walk indoors in bare feet with small steps. The pain is both with toe extension at push off in walking (a tiny bit of pain in passive extension but not much)  but there is also a feeling like I'm walking over a hard lump on the bottom of the ball of the big toe. In fact at first I thought I had done something to my sesamoids.

I recently was so desperate that I even bought expensive Finn rocker shoes and those don't seem to help-I can still feel the right big  toe at pushoff.  I've bought an infrared light to reduce the inflammation, take Epsom salt baths which help somewhat, I pull gently on the big toes with the movements you've shown in one of your videos, and I take the toe passively through extension (which oddly doesn't hurt-it's painful mainly in weight bearing). All in all, a full time job. 

I also suspect that the way I walk has exasperated or even caused this issue since I walk with my big toe extensors being excessively active and I always poked holes in the tops of my shoes with my toes. I am willing to come to see you if necessary despite the travel.  If you have any advice I'd be so grateful since this has affected my quality of life. I fear this condition will only get worse so will do whatever it takes to improve it.

I'm including some recent xrays:

Right foot showing signs of big toe joint arthritis with spurring

Both feet showing top of the big toe joint spurring and right side sesamoid irregularity

Moderate to severe osteoarthritis of the first MTP joints is demonstrated bilaterally. No soft tissue calcification present.
IMPRESSION: Osteoarthritis.

Dr Blake's response: Thank you so very much for emailing. The right foot looks more painful, is it not? At least, the right side has less motion, or does it? Here is a link to my basic post on hallux limitus treatment.

This is one of the original blog posts in 2014 that may help. 

  Hallux Rigidus means severe wear and tear on the big toe joint. The cartilage is tired, beat-up, and aggravated. The normal motion of the joint is significantly restricted, so attempts to move the joint normally can produce mild to severe pain. There is a lesser version of this called Hallux Limitus, which has significantly more motion, and a different treatment protocol.

     Hallux Rigidus develops over many years, with sometimes smoldering pain episodes, and may never really bother the patient. The joint is actually self-fusing, and getting less vulnerable. I had a great runner as a patient once that was having smoldering symptoms with severe advanced Hallux Rigidus. Luckily he ignored the surgeons, following simple conservative advice, and then proceeded to set a Guiness World Record for 6 marathons in 6 months all under 2 hours and 20 minutes!!

     But, some patients with Hallux Rigidus are not so charmed. They do something, quite ordinary usually, that develops moderate to severe pain. And they have trouble turning off that pain with self methods, x rays taken by the first doctor show the severe arthritis, and surgery is recommended. I maintain that Hallux Rigidus should be treated as a sore joint and nothing else. How do you get a sore joint calmed down? Usually, immobilization to rest the joint, shoes and orthotic devices to limit the big toe joint motion, taping to limit the toe motion, and then pile on the anti-inflammatory measures---icing, contrasts, meds, physical therapy, flector patches, topicals, accupuncture, and injections.

     The treatment of Hallux Rigidus is then divided into 2 columns--immobilization and anti-inflammatory. I challenge the doctors, physical therapists, and other health care providers to do all you can to calm the joint down and get it comfortable, even if this means 3 months in a removable cast (last resort). Once the joint is calmed down, and pain is gone, gradually increase activities pain free. See what it takes to stay pain free. See if there is any disability the patient does not want to live with, that you can guarantee with reasonable degree, would be removed if you did surgery.

     Let us say that you get the joint calmed down, but every time you try to run, the joint flares up. And you want to run, too young to give it up and you are willing to consider surgery. Xrays will show a bad joint with many bone spurs. There is no good surgery with Hallux Rigidus, so if I needed it, I would follow the KISS principle (see separate post). I follow the same thought process as with knees--cleanup with meniscus tears, more cleanup, a third cleanout when needed, a parital knee replacement when needed, and a total knee replacement when needed, and hopefully every surgery is the last surgery. So, with Hallux Rigidus, I recommend a joint cleanout (called arthroplasty or cheilectomy--try pronouncing those), perhaps another joint cleanout, a total replacement, another total replacement, and then a lot of deep thought before joint fusion is considered. Golden Rule of Foot: With Hallux Rigidus, Joint Fusion should be the last resort. 

So, if we make you a checklist for right now:

  1. You need to create that 0-2 pain level by removable boot, hike and bike shoe, Hoka One One with orthotic/dancer's padding/spica taping and some daily anti-inflammatory measures.
  2. This is so devastating that getting an MRI at least on the worst side, and you could send me a copy. 
  3. Find out if you have any bone issues (get bone density test and Vit D blood level).
Hope this gets us started!! Rich

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.